As Doctors Cater to Looks, Skin Patients Wait

NATASHA SINGER

Monday

Jul 28, 2008 at 4:34 AM

Dermatology is becoming a two-tier business in which higher-paying customers are often pampered.

Dr. Donald Richey, a dermatologist in Chico, Calif., has two office telephone numbers: calls to the number for patients seeking an appointment for skin conditions like acne and psoriasis often go straight to voice mail, but a full-time staff member fields calls on the dedicated line for cosmetic patients seeking beauty treatments like Botox.

Dr. Richey has two waiting rooms. The medical patients’ waiting room is comfortable, but the lounge for cosmetic clients is luxurious, with soft music and flowers.

And he has two kinds of treatment rooms: clinical-looking for skin disease patients, soothing for cosmetic laser patients.

“Cosmetic patients have a much more private environment than general medical patients because they expect that,” said Dr. Richey, who estimated that he spent about 40 percent of his time treating cosmetic patients. “We are a little bit more sensitive to their needs.”

Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.

In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients.

Dr. David M. Pariser, a dermatologist in Norfolk, Va., and the president-elect of the American Academy of Dermatology, said some practices did maintain preferential policies for cosmetic patients.

“The message is that the cosmetic patient is more important than the medical patient, and that’s not a good message,” Dr. Pariser said.

At a time when dermatologists are trying to advance the idea of a national skin cancer epidemic, such a two-tier system is raising concerns that the coddling of beauty patients may divert attention from skin diseases.

A study published last year in The Journal of the American Academy of Dermatology found that dermatologists in 11 American cities and one county offered faster appointments to a person calling about Botox than for someone calling about a changing mole, a possible sign of skin cancer.

And dermatologists nationwide are increasingly hiring nurse practitioners and physicians’ assistants, called physician extenders, who primarily see medical patients, according to a study published earlier this year in the same journal.

“What are the physician extenders doing? Medical dermatology,” Dr. Allan C. Halpern, chief of dermatology at Memorial Sloan-Kettering Cancer Center in Manhattan, said in a melanoma lecture at a dermatology conference this year. “What are the dermatologists doing? Cosmetic dermatology.”

There are no published studies showing that the rise of beauty procedures has caused harm to medical dermatology patients. If patients with skin problems have difficulty getting appointments, it is because over the last 30 years the demand to see skin doctors has far outstripped the number of physicians trained in the specialty, said Dr. Jack S. Resneck Jr., an assistant professor of dermatology at the medical school of the University of California, San Francisco.

Dr. Resneck, who researches professional issues in dermatology, said about 10,500 dermatologists now practiced in the United States, the majority devoting little time to vanity medicine.

Even so, dermatologists perform several million beauty treatments annually, according to estimates by the American Society for Dermatologic Surgery, including more than two million anti-wrinkle injection treatments last year — an increase of 130 percent over 2005.

Several patients interviewed for this article said that they believed the dermatologists they visited for medical care treated them as potential cosmetic consumers. Dianne Ryan, who works for an airline in Dallas, went to a dermatologist in her insurance network three years ago after her husband pointed out a mole growing on the side of her foot, she said. The doctor dismissed the mole as benign, she said, but recommended she buy his brand of bleaching cream for pigmentation on her face.

A few months later, Ms. Ryan said, she sought a second opinion from another dermatologist, whose diagnosis was melanoma.

“I don’t know if dermatology, with all the new technology, is turning away from melanoma or whether it is the glamour and excitement,” said Ms. Ryan, who was called by this reporter after an exchange in a chat room of the Melanoma Research Foundation. “If you do an extreme makeover on someone, you are a hero.”

Dermatology is one of the fields — along with plastic surgery and behavioral sleep medicine — in which patients are not only willing to pay for quality-of-life treatments that may not be covered by insurance, but also willing to pay much more for such treatments than insurers would pay for a medical procedure that takes a similar amount of time.

Some health insurers reimburse a doctor $60 to $90 for a visit including a full-body skin cancer check that might take 10 minutes; for Botox injections to the forehead, a doctor might receive $500 for 10 minutes, paid on the day of treatment.

According to a presentation for doctors from Allergan, the makers of Botox, a medical dermatology practice might have a net income of $387,198 annually, but a dermatologist who decreased focus on skin diseases while adding cosmetic medical procedures to a practice could net $695,850 annually. The same material advises doctors to “identify and segment high priority customers.”

People who wish to avoid a cosmetic-driven practice should simply seek appointments with medical dermatologists who focus on skin diseases, said Dr. Alexa B. Kimball, the vice chairwoman of dermatology at Massachusetts General Hospital in Boston.

But many dermatologists now offer both medical treatment and beauty procedures, which can confuse patients. And some doctors differentiate between patients — either within their own practices or by treating cosmetic patients in stand-alone facilities called medical spas.

Lecturers at the annual meeting of the American Academy of Dermatology, held in San Antonio in February, encouraged such segregation.

For example, Dr. Jason R. Lupton, a dermatologist in Del Mar, Calif., advised young physicians to oblige cosmetic patients by giving them appointments within seven days; empty appointment slots could later be filled with general dermatology patients, he said.

In a follow-up telephone interview, Dr. Lupton said that, in his own practice, he accommodated medical and cosmetic patients equally.

In an interview, Dr. Susan H. Weinkle, a dermatologist in Bradenton, Fla., said that she typically spends more time with cosmetic patients because they come in wanting to look better, the kind of amorphous desire that takes longer to satisfy than defined medical problems. One of her staff members always calls a beauty client to follow up, she said.

“It is very rare that you would call an acne patient and say, ‘How are you doing with that new prescription?’ ” Dr. Weinkle said. “But with a cosmetic patient, the consultant calls them the next day.”

This dual-class treatment system is not limited to the fanciest of private practices. Even academic institutions like the University of Michigan Health System in Ann Arbor are openly catering to beauty consumers. The Web site of the dermatology department warns a medical patient seeking an appointment to obtain a referral from a primary care physician “regardless of your type of insurance.”

Meanwhile, the same Web site — www.med.umich.edu/derm/patient/cdlcappointment.shtml — promotes the attentiveness of its cosmetic doctors and encourages those seeking vanity procedures to ask about the “convenient” valet parking.

A new profession — called aesthetic practice consultant — has emerged to advise doctors in the care of cosmetic patients.

“Instead of laying on an exam table with a paper liner, you have them lay on a sheet,” said Deborah Bish, a former nurse who works as a practice consultant in Yardley, Pa. “You have to class it up for these patients.”

It makes economic sense that dermatologists competing for Botox dollars want to create enticing environments, said Julie Cantor, a lawyer and medical school graduate who teaches a course in medical ethics at the law school of the University of California, Los Angeles. But Ms. Cantor said research was needed to determine whether such environmental changes alter a doctor’s behavior with medical patients.

“If you really started treating patients differently based on their ability to pay out of pocket, that’s a real problem,” Ms. Cantor said. “People who want their wrinkles fixed to go to a wedding should not be treated better than those who have psoriasis.”

Dr. Richey, the Chico, Calif., dermatologist, said that in his practice, the attention to cosmetic patients had no bearing on the treatment of medical patients; he maintains daily walk-in slots for medical patients with urgent skin problems, and many of his patients visit both sides of his practice.

“I don’t believe in differentiating,” Dr. Richey said.

Nonetheless, some medical patients said that they believed other dermatologists brushed off their medical concerns in favor of marketing cosmetic procedures. Melissa Bundy, a health communications manager in Atlanta, said that several years ago she went to a dermatologist who seemed more interested in selling face treatments than in conducting a thorough skin cancer examination. She has since switched doctors.

“Cosmetic things, it’s a really great business,” Ms. Bundy said. “But it really does seem to be at the expense of people like me getting the medical services that we are looking for.”

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